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Click here for more sample CPC practice exam questions and answers with full rationale

Physician orders for laboratory tests

Clinic is stating they placed an order for urinalysis ‘digitally’ so they don’t need to submit documentation for the UA. I’m unable to code it as there is no diagnosis or intent for the procedure indicated. What are the documentation requirements for a physician ordered laboratory test? Shouldn’t there be a document in the medical record that corresponds to the ‘digital’ order?

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